Basic Information
| Provider Information | |||||||||
| NPI: | 1467647628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | CAROL | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 N RITTER AVE | ||||||||
| Address2: | STE 230 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173557744 | ||||||||
| FaxNumber: | 3173558750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34000711A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | 34006797A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000856452 | 01 | IN | ANTHEM BCBS | OTHER |